LNSLNS

The inclusion criteria, which Dr. Müller requested, are described in the Methods section of our article (1). In the prospective study, 653 patients were included consecutively, without exclusion criteria in order to prevent selection effects. Relating to the guidelines of the German Professional Association of Environmental Medicine (dbu), we would like to point out that the term “guideline” is not protected. Beside the scientifically accepted guidelines of the Association of Scientific Medical Societies in Germany (AWMF, Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V.), there are guidelines in varying quality published by other societies. The diseases described in the study by Hänninen (2) are not specifically environmental diseases and can therefore be diagnosed and treated according to AWMF guidelines. We attempted to present our results objectively and without polemics, since a respectful relationship with colleagues is very important to us.

Dr. Klehmet first points out that a distinction must be made between acute and chronic exposure. However, this differentiation is only possible by using the history and the kinetics of the foreign substances or their metabolites, since quantification of burden cannot distinguish between acute and chronic effects. It is correct that the lymphocyte transformation test is an immunological procedure. Nonetheless, only the type IV allergy from the Gell and Coombs classification can be detected, but not general immunological disturbances. The hypothesis of a clinical significance of genetic polymorphisms (susceptibilities) for detoxification has been controversially discussed in environmental medicine for 25 years. As long as there is no scientific evidence to show that these are also relevant in clinical environmental medicine, using genetic polymorphism determination for individual diagnosis based on an environmental medical issue cannot be recommended (3, 4).

Peter Jennrich comments in particular on the importance of the use of chelating agents. Without a doubt, chelating agents lead to increased excretion of metals in the urine. In particular, the first urine fraction obtained after administration of the chelating agent contains very high concentrations of metals. Thus, extrapolating of the concentration in the first urine fraction to one liter urine or even to a 24-hour excretion is therefore not possible. The metals are primarily mobilized from the blood and kidneys. Since the mobilization values are closely related to the respective initial values of the spontaneous Hg excretion, the test procedure does not yield any significant additional findings on Hg loading or storage (5). Thus, considering their potential side effects, using a chelating agent with of non-recognizable diagnostic value cannot be justified. Furthermore, there are no generally accepted reference values, so the metal concentrations can hardly be assessed after mobilization. The cited statement of the Umweltbundesamt (UBA) in this regard relates to the diagnosis of aluminum intoxication in renal insufficiency patients, but not to environmental medical questions, and thus is not related to our article. 

DOI: 10.3238/arztebl.2017.0253

Dr. med. Annette Greiner, Prof. Dr. med. Drexler

Institut und Poliklinik für Arbeits-, Sozial- und Umweltmedizin

Universität Erlangen-Nürnberg, Germany

annette.greiner@fau.de

Conflict of interest statementt

All authors of all contributions declare that no conflict of interest exists.

1.
Greiner A, Drexler H: Unnecessary investigations in environmental medicine—a retrospective cohort study. Dtsch Arztebl Int 2016; 113: 773–80 VOLLTEXT
2.
Hänninen O, Knol A: European perspectives on environmental burden of disease. Estimates for nine stressors in six European countries. Helsinki, Finnland: University Printing 2011.
3.
Schulz TG, Hallier E: Die Bedeutung von genetischen Polymorphismen Fremdstoff-metabolisierender Enzyme in der Arbeitsmedizin. Arbeitsmed Sozialmed Umweltmed 1999; 34: 307–14.
4.
RKI-Kommission „Methoden und Qualitätssicherung in der Umweltmedizin“: Genetische Polymorphismen (Sequenzvariationen) von Fremdstoff-metabolisierenden Enzymen und ihre Bedeutung in der Umweltmedizin. Bundesgesundheitsbl – Gesundheitsforschung – Gesundheitsschutz 2004; 47: 1115–1123 CrossRef MEDLINE
5.
Schiele R: Amalgam fillings—tolerance. Dtsch Zahnarztl Z 1991; 46: 515–8 MEDLINE
1.Greiner A, Drexler H: Unnecessary investigations in environmental medicine—a retrospective cohort study. Dtsch Arztebl Int 2016; 113: 773–80 VOLLTEXT
2.Hänninen O, Knol A: European perspectives on environmental burden of disease. Estimates for nine stressors in six European countries. Helsinki, Finnland: University Printing 2011.
3.Schulz TG, Hallier E: Die Bedeutung von genetischen Polymorphismen Fremdstoff-metabolisierender Enzyme in der Arbeitsmedizin. Arbeitsmed Sozialmed Umweltmed 1999; 34: 307–14.
4.RKI-Kommission „Methoden und Qualitätssicherung in der Umweltmedizin“: Genetische Polymorphismen (Sequenzvariationen) von Fremdstoff-metabolisierenden Enzymen und ihre Bedeutung in der Umweltmedizin. Bundesgesundheitsbl – Gesundheitsforschung – Gesundheitsschutz 2004; 47: 1115–1123 CrossRef MEDLINE
5.Schiele R: Amalgam fillings—tolerance. Dtsch Zahnarztl Z 1991; 46: 515–8 MEDLINE

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